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STATE OF CALIFORNN WATER RESOURCES CONTR BOARDJ" UNDERGROUND STORAGE TANK PROGRAM FORM `B': TANK PERMIT APPLICATION INFORMATION aro„ G TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY F-1 TANK REMOVED , (1 C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE J� 11 FARM TANK-YES NO ❑ N FACILITY/SITE NAME WHERE TANK IS INSTALLED: D l ,A I. TANKDESCRIPTION COMPLETEALLITEMS-IF UNKNOWN-SO S8,MANUFACTURED BY: 11 A. OWNERS TANK ID# -7`I D. TANK CAPACITY IN GALLONS: O G. YEAR INSTALLED 11. TANK CON NTS IF(0.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. � 11D ❑ C. ❑ 1 UNLEADED 2 LEADE3 DIESEL A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B' F-13 CHEMICAL PRODUCT F-14 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 2 WASTE ❑7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) ID 5 HAZARDOUS E]80 EMPTY [:]95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A TYPE OF ❑I DW WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM NGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER /IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 UEELCLADWIFIBERGLASSREINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYLCHLORIDE F-17 ALUMINUM ❑S 100%METHANOL COMPATI8LE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PH LINING C. INTERIOR ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN LINING ❑ IS UNING MA7DilAl COMPATIBLE WI1H 10D%METHANOL? E]YES ❑ NO ❑99 OTHER D.CORROSION ❑i POLYETHLENEWRAP ❑ 2TAR RASPHALT E]3 VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A dvSTEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS II.V Y`C P 8 6 PRECISION TESTING P S 7 PRESSURETESTING Ii; S 91 NONE P 8 95 UNKNOWN P S 99 OTHER 1 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN NB INERT MATERIAL? ❑YES [-]NO G1ILLO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O a S 0O � / CURREM140CAL AGENCY FACILITY IDJL APPROVE BY N vE PHONE N WITH AREA CODE fU\ S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-m) THIS FORM MUST BE ACCOMPARWID BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _